title: Spinal cord localization in the treatment of lung cancer: use of radiographic landmarks.
abstract: OBJECTIVE
  In the treatment of thoracic malignancies with radiotherapy, the critical dose-limiting structure is the spinal cord. Oblique fields typically are designed to exclude the spinal cord, and by convention, the field edge that shields the spinal cord is placed at the anterior border of the vertebral pedicles. Thus, the purpose of our study was to estimate the distance between the field edge and spinal cord in oblique fields that were designed by using the vertebral pedicle as a radiographic landmark.
  
  
  METHODS
  The spinal cord of a cadaver was wrapped in wire, and oblique fields were simulated at 15 degree intervals. The distance from the spinal cord to a field edge placed at the anterior border of the pedicle was measured. In the second investigation, a three-dimensional treatment planning system was used to simulate hypothetical fields using actual patient data from computed tomography (n = 10), and measurements identical to those in the anatomical model were made (n = 1,100).
  
  
  RESULTS
  The results of the anatomical and computed tomographic models were in close agreement (mean difference, 0.6 mm). The computed tomographic model predicted a mean field edge to spinal cord distance of 8.7 mm (95% confidence interval, 5.6-11.8 mm) for 30 degree/150 degree oblique fields and 8.0 mm (95% confidence interval, 4.7-11.7 mm) for 45 degree/135 degree oblique fields. This distance was greatest at levels T-1, T-2, and T-11 (8 to 20% greater).
  
  
  CONCLUSIONS
  The mean distance from a field edge placed at the anterior border of a vertebral pedicle to the spinal cord for commonly used oblique angles constitutes a sufficient margin to account for expected differences in daily positional variations and mechanical uncertainties.
authors.affiliation: Department of Radiation Oncology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA.
authors.forename: R C
authors.initials: RC
authors.lastname: Miller
authors.forename: J A
authors.initials: JA
authors.lastname: Bonner
authors.forename: D E
authors.initials: DE
authors.lastname: Wenger
authors.forename: R L
authors.initials: RL
authors.lastname: Foote
authors.forename: K L
authors.initials: KL
authors.lastname: Kisrow
authors.forename: E G
authors.initials: EG
authors.lastname: Shaw
mesh_terms: D002102:Cadaver; D003198:Computer Simulation; D006801:Humans; D008175:Lung Neoplasms / Q000532:radiotherapy*; D008953:Models, Anatomic; D011859:Radiography; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods*; D013116:Spinal Cord / Q000033:anatomy & histology / Q000000981:diagnostic imaging*